Coding in home health care is critical, especially with the Patient Driven Groupings Model (PDGM) and the Face-to-Face encounter rule. Accurate coding impacts both quality reviews and reimbursement. The primary diagnosis from the Face-to-Face encounter drives the PDGM clinical grouping, while secondary diagnoses affect comorbidity status. Incorrect coding means incorrect payment.
It’s vital that the primary diagnosis on the care plan matches what was treated during the Face-to-Face encounter and is documented in the encounter note. Building on our previous discussion, here are key tips to ensure accurate diagnosis coding and avoid common Face-to-Face encounter pitfalls in home health.
Tip 1: Address New Wounds in the Face-to-Face Encounter
If a clinician finds a wound that wasn’t in the original Face-to-Face encounter but is now the main reason for home health services, a new Face-to-Face encounter is mandatory. This encounter must document the physician’s assessment and treatment of the wound.
Failing to do so can lead to denials with the reason: “The required face-to-face encounter is not related to the primary reason for home health services.” Always ensure the primary diagnosis for home health is actively addressed in a documented Face-to-Face encounter.
Tip 2: Addendums and Diagnosis Queries Are Not Substitutes for Active Treatment
For a wound or condition that is the primary reason for home health and the principal diagnosis, it must have been actively treated during the Face-to-Face encounter.
An addendum cannot retroactively document treatment that did not occur during the initial encounter. Similarly, a diagnosis query confirming a condition not actively treated during the encounter will not meet Face-to-Face requirements. The encounter note must reflect active management of the primary diagnosis.
Tip 3: Understand “Active Treatment” in Face-to-Face Encounters
Auditors look for diagnoses actively treated during the Face-to-Face encounter, though “active treatment” isn’t precisely defined. However, simply listing diagnoses with instructions like “continue meds,” “stable,” or “continue to monitor” without evidence of active management can cause audit issues.
Active treatment implies the physician took steps to evaluate or manage the condition during the encounter. Documentation should reflect more than just a passive acknowledgement of existing conditions.
Tip 4: Physician Addendums for Omitted Documentation of Actual Treatment
If active treatment did occur during the Face-to-Face encounter, but was not clearly documented, a physician addendum to the original encounter note is acceptable. This addendum must be from the physician who performed the encounter and must specifically detail treatment that took place on the encounter date but was inadvertently omitted.
Crucially, addendums created by the home health agency and merely signed by the physician are not valid. The documentation correction must originate from the physician’s practice and be directly linked to the original Face-to-Face encounter.
Tip 5: When a New Face-to-Face Encounter is Definitely Required
Several situations necessitate a new Face-to-Face encounter:
- Resolved Condition: When the condition actively treated during the initial encounter is documented as resolved.
- Non-PDGM Primary Diagnosis: If the actively treated condition isn’t an acceptable primary diagnosis under PDGM guidelines.
- Pre-op Notes for Post-op Care: When the Face-to-Face encounter is solely a pre-operative note, but home health focuses on post-operative skilled care. The post-operative condition needs to be addressed in a separate encounter if it’s the primary reason for home health.
- Inpatient Stay Notes without Direct Home Health Admission: If the Face-to-Face encounter is from an inpatient stay and the patient was not directly admitted to home health afterward. A community-based Face-to-Face encounter might be needed.
- Community Physician Notes and Certifying Practitioner Differences: If the Face-to-Face encounter is from a community physician (urgent care, specialist) who is not the certifying physician or a non-physician practitioner under the certifying physician. Notably, if a non-physician practitioner is certifying, the community Face-to-Face must also be by the same type of non-physician practitioner.
These scenarios highlight instances where the initial Face-to-Face encounter may not adequately support the primary diagnosis for home health services, requiring a new, specific encounter.
Tip 6: Avoid Coding Before a Valid Face-to-Face Encounter is Obtained
Coding patient charts before securing a valid Face-to-Face encounter note is strongly discouraged. This practice often leads to audit issues and increased administrative work due to the need for recoding.
Some agencies prematurely finalize care plans and seek physician certification before the Face-to-Face visit is even complete. This is problematic because certification requires confirming the Face-to-Face encounter date, which is impossible until the encounter has occurred.
It’s best practice to never code a new Start of Care Plan of Care without a proper Face-to-Face encounter note in hand. Waiting for the valid encounter documentation prevents potential coding errors and ensures compliance from the outset.
By adhering to these Home Health Care Coding Tips, agencies can improve their documentation accuracy, ensure proper reimbursement under PDGM, and minimize audit risks related to Face-to-Face encounters. Focusing on these key areas will contribute to smoother operations and financial stability in the evolving landscape of home health care.
